Prevalence of common mental disorder and its association with perceived stigma and social support among people living with HIV/AIDS in Ethiopia: a systematic review and meta-analysis

Background When common mental disorders (CMD) co-occur with HIV/AIDS, they can complicate patient diagnosis, help-seeking behaviors, quality of life, treatment outcomes, and drug adherence. Thus, estimating the pooled prevalence of CMD and its association with perceived stigma and social support among people living with HIV/AIDS (PLWHA) in Ethiopia could potentially support policymakers and health professionals to understand the disease burden and set a solution to improve the mental well-being of PLWHA. Methods Popular databases such as PubMed, SCOPUS, EMBASE, and Psych-INFO as well as Google Scholar, AJOL, CINAHL, PILOTS and Web of Science were searched for the relevant articles conducted in Ethiopia. We included cross-sectional, case–control, and cohort studies in the review. The Comprehensive Meta-Analysis software version 3.0 was used to pool the results of the included studies. The Q- and I2-statistics were used to assess the heterogeneity between the included studies. We employed a random-effects meta-analysis model to estimate the pooled prevalence of CMD and to account for heterogeneity among the included studies. We also conducted a leave-one-out analyses, and stratified meta-analyses by gender (male and female). Results The studies included in this systematic review and meta-analysis were published between 2009 and 2021, recruiting a total of 5625 participants. The pooled estimated prevalence of CMD among PLWHA in Ethiopia was 26.1% (95% CI 18.1–36.0). The pooled estimated prevalence of CMD was significantly higher among females, at 39.5% (95% CI 21.2–39.0), compared to males, 26.9% (95% CI 15.6–31.7). Moreover, the pooled estimated prevalence of CMD in PLWHA ranged from 23.5 to 28.9% in the leave-one-out sensitivity analysis, indicating that the removal of any single study did not significantly affect the pooled estimate. The pooled effects (AOR) of Perceived HIV stigma and poor perceived social support on common mental disorder were 2.91, 95% CI (1.35–6.29) and 5.56, 95% CI (1.89–16.39), respectively. Conclusion People living with HIV/AIDS (PLWHA) who received poor social support and those with HIV-related perceived stigma were found to have strong association with CMD. Therefore, it is advisable that all PLWHA attending ART clinic should be screened for CMD, social support and HIV-related perceived stigma. Supplementary Information The online version contains supplementary material available at 10.1186/s13033-024-00641-x.


Background
Common mental disorder (CMD) refers to a group of mental health disorders that include depression, anxiety, and somatoform disorders with a significant contribution to the burden of disease in the middle-and low-income countries [1].According to systematic review and metaanalysis of 174 surveys across 63 countries in 2014, the global lifetime prevalence of CMD was 29.2% [2].CMDupsurges the risk of emerging both communicable and non-communicable diseases in all age groups of the general population [3].CMD is frequently reported among HIV infected individuals and it is the leading cause of infirmity among PLWHA [4][5][6].
Based on the reports from studies conducted in the low and middle-income countries (LMICs), the prevalence of CMD was found to be high [7][8][9].For example, a study conducted in Zimbabwe using the Shona Symptom Questionnaire (SSQ14 > = 9) reported 68.5% prevalence of CMD s among PLWHA (7).In contrast, another study from South Africa showed that 23.9% of people living with HIV reported symptoms of CMD [8].Further, finding from the Nigerian study that used the Kessler Psychological Distress Scale (K10) to assess CMD reported 47.9% of PLHIV participants scored ≥ 20, suggesting CMD [9].
Female gender, poverty, and stressful life events were found to be common determinants of CMD in non-HIV populations [10].In other studies, correlates of CMD in PLWHA include the death of a significant other [11], family history of mental illness, poor coping style, alcohol dependency, food insecurity [12], exposure to negative life events [7,13], posttraumatic stress disorder (PTSD) and perceived HIV stigma [14][15][16].Additionally, factors such as poor social support, not disclosing HIV status, stressful feelings about the illness were significant provoking factors [17,18].
Research has shown that individuals with CMD experience accelerated progression from HIV to AIDS [19].Additionally, these individuals may have difficulty adhering to ART treatment [20], which can lead to increased viral load and death in patients with AIDS [21,22].However, effective management of CMD has been found to improve the health and quality of life of PLWHA [22,23].Although several studies have been conducted in Ethiopia to assess CMD among PLWHA [17,[24][25][26][27][28][29][30][31][32][33], there is significant inconsistency in the prevalence of CMD across the studies in the topic.Furthermore, there have been no previous systematic reviews or meta-analyses conducted on this topic in Ethiopia.Therefore, this review aimed to systematically review previous studies, summarize the magnitude of CMD, and examine their association with HIV-related perceived stigma and social support among PLWHA in Ethiopia.This review also aimed to formulate recommendations for future better clinical services.

Search strategy and selection process
We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to conduct this systematic review and meta-analysis [34].A predesigned study protocol for database searching, data extraction, inclusion-exclusion criteria, and quality evaluation was used.PubMed, SCOPUS, EMBASE, and Psych INFO databases were searched for relevant articles that assessed the prevalence of CMD among PLWHA in Ethiopia using the following search terms and keywords: (epidemiology OR prevalence OR magnitude) AND (common mental disorders OR psychological distress OR common mental illness OR psychiatric morbidity OR mental health problems) AND (associated factors OR correlates OR risk factors OR determinants) AND (people living with HIV/AIDS OR HIV patients OR HIV/AIDS) AND Ethiopia.Furthermore, we searched EMBASE, SCOPUS, and Psych INFO using databasespecific subject headings.The search yielded relevant articles that were assessed for inclusion in the study.We also searched for articles indexed in Google Scholar, African Index Medicus, African Journals Online (AJOL), CINAHL, PILOTS and Web of Science.

Eligibility criteria
We included cross-sectional, case-control, and cohort studies conducted either in community or institutional settings and assessed the prevalence and factors associated with CMD s or psychological distress among PLWHA in Ethiopia.Commentaries, editorials, reviews, and letters to editors were excluded from the review.

Methods for data extraction and quality assessment
Two independent reviewers (BD and AB) conducted data extraction based on the predefined data extraction form.The data extraction form included the authors' names, year of publication, sample size, study design, study setting, and the instrument used to measure common mental disorders as well as associated factors along with adjusted odds ratios.The Newcastle-Ottawa Scale (NOS), adapted for cross-sectional studies was used to check the methodological quality of studies included in the review [35].This tool has been used in previous studies [36,37].The NOS scale assessed the quality of studies based on methods, sample size, sample representativeness, and comparability between participants.The agreement between the evaluators was appraised using the unweighted kappa statistic (YB and AB).The levels of agreement were categorized as poor (0), slight (0.01-0.20), fair (0.21-0.40), moderate (0.41-0.60), substantial (0.61-0.80), and almost perfect (0.81-1.00) [38].

Data synthesis and analysis
We systematically reviewed qualitative data, including the identification of studies, study characteristics, and the quality of the included studies.Comprehensive Meta-Analysis software version 3.0 was used to conduct a meta-analysis, employing a random-effects meta-analysis model to pool the overall prevalence of CMD among PLWHA in Ethiopia [39].We also computed pooled adjusted odds ratio (AOR) for factors associated with CMD among PLWHA.The Q-and the I 2 -statistics were used to assess the heterogeneity between the studies [40], with values of 25, 50 and 75% indicating low, low, medium and high level of heterogeneity, respectively [40].Publication bias was evaluated by using Egger's test and visual inspection of funnel plot [41].The level of significance was set at P < 0.05.Furthermore, we conducted a metaregression to quantify the impact of the screening tools used to measure CMD, gender, and region a study originated on the observed heterogeneity across the studies included in the review.

Identification of studies
A total of 162 articles were identified through electronic database searching.Besides, five more articles were obtained from references of the included articles.Out of the 167 articles, 142 were excluded as they did not meet the eligibility criteria (Fig. 1).Subsequently, 25 articles were selected for further screening, out of which 14 full text articles were excluded.Finally, 11 full-text articles were included in the final systematic review and meta-analysis.

Characteristics of included studies
The studies included in the current systematic review and meta-analysis were published between 2009 and 2021 and recruited a total of 5625 study participants.Ten studies employed a cross-sectional study design, whereas one study used a cohort study design.Two studies were conducted in South Nation Nationalities and People Regional States, three in the Amhara region, five studies in the Oromia region, and one in the Harar region.Four studies used the Self-Reporting Questionnaire item 20 (SRQ20), one study used Hospital Anxiety and Depression scale (HADS) and six studies used the Kessler scale (K-10) (Table 1).

The quality of studies included in the review
Based on the Newcastle-Ottawa Scale, 8 studies were of high methodologic quality, whereas three studies were of moderate methodologic quality.The agreed levels between the authors regarding the quality of the studies included the meta-analysis ranged from moderate to almost perfect levels (Supplementary file 1).

Sensitivity analysis
We performed a leave-one-out sensitivity analysis to identify the possible source of heterogeneity in the pooled meta-analysis of the prevalence of the CMD among PLWHA in Ethiopia.This sensitivity analysis involves performing a meta-analysis on each subset of the studies obtained by leaving out exactly one study at a time.This approach helps to determine how the removal of each study affects the overall estimate of the remaining studies.The pooled prevalence of CMD ranged between 23.5% (16.5-31.7%)and 28.9% (20.5-39.0),suggesting the pooled estimated prevalence of the CMD among PLWHA was not significantly affected by the removal of any single study (Table 2).

Meta-regression
In this systematic review and meta-analysis, we first employed univariate regression analysis to guide the selection of the associated factors to include in the final meta-regression model.In the final meta-regression model, we quantified the impacts of the screening tools used to measure the CMD the gender of the study participants (male or female), and the region where the study was originated.The overall proportion of variance explained by the tools used to assess CMD, the gender of the study participants, and the study region was analyzed in the final model.The overall proportion of variance explained by the gender of the study participants and the region the study was conducted were 34% (R 2 = 34%; P-value = 0.02) and 6% (R 2 = 6%; P-value = 0.34) respectively.Except for the gender of the study participants, neither the tools used to assess the CMD nor the region where the studies were originated were statistically significant determinants for the observed variation in the prevalence of the CMD among studies included in this review.

Statistical analysis of factors associated with CMD
In our statistical analysis of factors associated with CMD among PLWHA in Ethiopia, we identified two determinants that were commonly adjusted for in the studies included in this systematic review and metaanalysis.The pooled adjusted odds ratios (AOR) of perceived HIV-related stigma and perceived poor social support on CMD were 2.91, 95% CI (1.35-6.29)and 5.56, 95% CI (1.89-16.39)),respectively (Table 3).

Discussion
In this systematic review and meta-analysis, we examined the pooled prevalence of CMD among PLWHA in Ethiopia.The final meta-analysis included eleven studies, and the pooled prevalence of CMD among PLWHA was 26.1%.This implies that CMD is a major public health problem among PLWHA in Ethiopia.The pooled prevalence of CMD in this review was in line with a study conducted in South Africa, which reported a prevalence rate of 23.9% (8).A cross-sectional study conducted in southwest regional hospitals of Cameroon among PLWHA on HAART also reported a similar prevalence rate [43].Furthermore, a study conducted in Ethiopia to assess the prevalence of CMD among patients with glaucoma reported a similar prevalence rate of (23.2%) [44].Nevertheless, the pooled estimated prevalence of CMD among PLWHA was lower than the findings of a study from a Nigerian teaching hospital, which showed a prevalence rate of ( 47.9%) [9].Further, a study on psychological distress among Ugandan female adolescents living with HIV reported a much higher CMD prevalence rate of 53% [45].A cross-sectional survey conducted in Zimbabwe at a large primary health care facility found a CMD prevalence rate of 68.5% using locally to identify factors associated with CMD using locally validated screening tools, namely the Shona Symptom Questionnaire (SSQ-14) [7].
In contrast, the pooled estimated prevalence of CMD was higher than the findings from studies conducted in East Zimbabwe among individuals living with HIV [46] and in the general community of Kenya [45].The variation in the prevalence of CMD might be attributed to the difference in geographical, cultural, and socio-economy status of the study areas as well as the difference in the study populations.For example, a study conducted in Uganda only included female adolescents aged 12-19 living with HIV [45].
The prevalence of CMD in the current meta-analysis was significantly higher in females (39.5%) compared to males (26.9%).This finding aligns with prior study that has shown a higher prevalence of CMD among females Logit event rate

Funnel Plot of Precisionby Logit event rate
Fig. 3 Funnel plot shows no evidence of publication bias among studies included in the meta-analysis than males [45].For example, a study assessing the prevalence of psychological distress among individuals in HIV Care Service Utilization in East Zimbabwe found a prevalence of 4.5% among men and 12.9% among women [46].This variation may be attributed to specific forms of depression-related illness experienced by women, such as premenstrual dysphoric disorder, postpartum depression, and postmenopausal mental illness, which are linked with changes in ovarian hormones that may have contributed to the observed difference in the prevalence of CMD among PLWHA [47,48].
People living with HIV/AIDS who reported HIV -related perceived stigma were approximately three times more likely to have CMD compared to their counterparts.Of the eleven studies included in the review, four reported statistically significant associations between perceived stigma [26][27][28][29].Individuals who experience stigma may develop a poor self-image and become socially isolated, which can increase their risk of developing CMD [49].Furthermore, perceived stigma may lead to internalized prejudice and negative self-perceptions, resulting in decreased self-esteem and further contributing to the progression of CMD PLWHA [50].These negative self-perceptions and social isolation can limit social interactions and affect occupational functioning thereby increasing the risk of CMD.
Furthermore, PLWHA who reported poor social support were approximately 6 times more likely to have CMD compared to those with better social support.This finding was supported by three of the studies included in the review [17,27,29].Poor social support can trigger feelings of social isolation and negatively impact both physical and mental well-being [26][27][28].This is consistent with the social causation model, which suggests that a lack of social support increases the likelihood of CMD, such as depression [51,52] Conversely, good social support may alleviate CMD by improving self-esteem and reducing negative thoughts [53,54].

Conclusion
This review found that the pooled prevalence of CMD among PLWHA was considerably high.Our findings suggest that PLWHA who receive poor social support and those experiencing HIV-related perceived stigma are at a greater risk of developing CMD.Therefore, it is advisable that all PLWHA attending ART clinics be routinely screened for CMD, social support, and HIVrelated perceived stigma.In addition to this, health professionals, more specifically, clinical psychologists and mental health professionals should provide regular counselling to enhance stress-coping mechanisms and improve the mental well-being of PLWHA attending ART clinics.Finally, we recommend that researchers consider conducting a large -scale longitudinal studies to further explore the burden and risk factors of CMD among PLWHA.

Limitations of the review
The following are the limitations of our systematic review and meta-analysis that should be considered when interpreting our findings.First, only eleven studies published in the past ten years met the inclusion criteria.Second, due to variations in diagnostic approaches, the tools used to screen CMD may be prone to measurement bias.However, we have addressed this issue of heterogeneity during our analysis, which provides more reliable estimate of CMD and its associated factors among PLWHA in Ethiopia.

Fig. 1
Fig. 1 PRISMA flowchart of review search

Table 1
Characteristics of studies included in the review

Event rate and 95% CI
Tesfaye and BuneFig.2Theprevalence of CMD among PLWHA in Ethiopia: a meta-analysis

Table 2
Sensitivity analysis of CMD among PLWHA in Ethiopia for each study being removed at a time: prevalence and 95% confidence

Table 3
Factors associated with CMD among PLWHA that were commonly adjusted in the included studies